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On So-Called Binasal Hemianopsia in Brain Tumor

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On So-Called Binasal Hemianopsia in Brain Tumor tion of these various products is inert, perhaps authoritative writers, the one unsurpassed in it is inactivated or its activity greatly retarded the field of cerebral surgery, the other unsur- by the various menstrua. We see that scale pep- passed in the field of perimetry, cannot fail to sin, 15 grs. to a fl. 5 ss of distilled water, re- carry great weight. duced the albumin to 4^4 grs. (Test Series Quoting from their paper (p. 597) :— No. 5, Tube No. x), and to 33,4 grs. (Test Series "A constriction of the field of vision due to a de- No. Tube No. vti). Scale in the pro- 6, pepsin struction of fibres more of found in the complete from the temporal portion .3% (as gastric juice) than from the nasal half of the retina and justify- did not exert any great effect, the albumin ing the designation of nasal hemianopsia has been 8 or 9 Series No. weighed grs. (Test 5, Tube observed in from 5 to 6% of a series of 500 cases of No. vin. The reader may make other deduc- brain tumor.". "It is difficult or impossible to at- tions by studying and comparing the tables. tribute the ultimate binasal blindness to a lesion The first three series demonstrated as far as confined alone to the nerve and retina. Another visible results could be judged, that the higher factor must come into play, which elsewhere in the course of the nerve affects uncrossed fasciculus temperature of 125° F. did not cause any greater the digestive effect than did the temperature of from the temporal retina more markedly than the 100° F. to 104° F. crossed fibres from the nasal retina. We wish to that this be due other tests suggest may to pressure of the di- Many could be performed along lated [third] ventricle, which forces the exposed these for of va- lines, instance, comparison the nerves or tracts adjoining the chiasm downward rious makes of scale pepsin; comparison of the and outward against the resistant carotid vessels, effect of the same preparation on albumin boiled which transversely indent the outer aspect of the for different periods of time, as ten, fifteen, nerves. In this way the uncrossed fasciculi to the twenty or thirty minutes; dried albumin might temporal retinae, and the laterally placed macular be used; indicators other than egg albumin bundle as well, suffer from a mechanical pressure could be employed; rocking water-bath might 'block' in addition to the diffuse anatomical de- be constructed to represent continuous peristal- struction of fibres throughout the nerve in conse- sis. quence of the contraction of the new tissue forma- tion in the long-standing choked disk." A practical inference suggests that when we we will prescribe pepsin probably get better re- The two points to be discussed are these: the sults scale as by ordering pepsin dispensed a occurrence of binasal hemianopsia and its expla- tablet, capsule, or in sealed packages, to be nation. dissolved water freshly in and taken about a half The of the occurrence of binasal hour after meals. If question hydrochloric acid is indi- hemianopsia is a question of definition. It is cated it may be dispensed separately and or- not easy to give a satisfactory brief definition. dered to be taken well diluted. the scale (All The three things to be emphasized are : first, the pepsin solutions were freshly made at the time loss should be limited to corresponding half of the tests.) fields; second, the loss should be symmetrically Undoubtedly pepsin, like other remedies, has distributed in the two the cause suffered from eyes; third, being improperly dispensed and should be a lesion to the visual centres or paths injudiciously used. Pepsin will not lift a fallen at or posterior to the chiasm, for the funda- stomach ; it will not cure the reflex gastric symp- mental anatomical fact at the foundation of the toms due to gall-bladder disease, chronic appen- idea of hemianopsia is the semidecussation of etc. The crux dicitis, of the whole subject de- the nerves. Cases are not uncommon that optic pends upon fascinating subject of diagnosis. where we get fields not unlike in extent and dis- My personal impressions are that pepsin's rôle tribution those classified as true in hemianopsia, therapeutics will be established and enhanced but of wholly different origin, for example, in its exhibition on exact by indications dependent chronic glaucoma and in retinal or choroidal on accurate diagnosis. lesions symmetrically disposed in the two eyes. These should not be classed as cases of true hemianopsia. They might be called pseudo- hemianopsia. That the authors had some such ON SO-CALLED BINASAL HEMIANOPSIA conception of true hemianopsia as above out- lined would appear from a statement which IN BRAIN TUMOR I quote from the first paper in this series2 :— BY WALTER B. LANCASTER, M.D., BOSTON. "Thus in considering the prevalence of true hemianopsia in a given series of intracranial tu- The third paper by Cushing and Walker1 in mors, one should exclude from the list the subten- torial lesions which are their series on distortions of the visual fields barred from the possibility in of direct implication of the optic tract and radia- cases of brain tumor is devoted to binasal tions." hemianopsia. The authors detail the histories of a dozen eases with many charts of the fields of To be sure, most of the eases described in the vision and reach several conclusions which are present paper are subtentorial but this of sufficient to tumors, importance warrant discussion, is explained when we recall that the more inconsistency so as any hypothesis backed by such the purpose of the paper is to show how such tu- The Boston Medical and Surgical Journal as published by > The New England Journal of Medicine. Downloaded from nejm.org at UNIV OF PENN LIBRARY on July 3, 2016. For personal use only. No other uses without permission. From the NEJM Archive. Copyright © 2010 Massachusetts Medical Society. mors can affect the optic pathway indirectly by disk. The field extends nasally 75° from the pressure of the third ventricle. disk and temporally 75° from the disk. If now a In the cases under discussion the matter is concentric contraction progresses with such uni- complicated by the fact that admittedly the formity that exactly 60° is lost from both nasal chief factor in the loss of vision is the secondary and temporal sides, 15° will be left on each side atrophy consecutive to choked disc. The binasal of the disk. This will leave "a small field cen- hemianopsia is not claimed to be the only fac- tering around the blind spot"—precisely what tor. Thus the question is not, are these fields the authors state3 is the typical finding in their typical of binasal hemianopsia, for of course cases. Are we not justified in saying that these they are not. The question is, are they typical fields are quite satisfactorily explained as due to of secondary atrophy complicated by binasal concentric contraction, the result of changes oc- hemianopsia 1 The presence of the atrophy will curring in the papilla? Were there an inter- account for the fields not conforming to the first current binasal hemianopsia grafted onto the and second requirements of the definition, for a fields, as claimed, we should expect to find that very superficial examination is sufficient to show before the temporal fields had contracted 30° or that the losses are not confined to the nasal fields 40° the process in the nasal fields would have ad- and that they are not even symmetrically dis- vanced with decidedly greater rapidity and tributed in the two nasal fields. At this point it would show a decidedly greater loss than the should be observed that the authors disarm criti- temporal. Assuredly, if we -are dealing with bi- cism by remarking:— nasal hemianopsia there must be a loss of sym- metrically disposed patches in the nasal "It somewhat to fields, may appear imaginative desig- over and above what we should to find if nate the field defects which expect accompany these case the loss were due to concentric contrac- reports as examples of for admit- merely hemianopsia, they and so with tedly fail to show the clean-cut vertical meridians tion, merely kept pace the loss found dividing the blind from the seeing retina, which on the temporal side. often (though not invariably) characterize certain In discussing visual fields it is important to stages of the homonymous and bitemporal field de- bear in mind the margin of error due to the fects, as will be indicated in the later papers in this nature of the phenomena we are measuring. series." There is in.most cases no sharp line of demarca- tion where we can say "on one side vision is To answer the question whether the fields are characteristic of binasal present, on the other side vision is absent and hemianopsia compli- whoever makes the test if find cating secondary atrophy we must first consider will, competent, what is the character of uncomplicated it so." One has only to try it on himself to typical appreciate this. Also the character of the re- secondary atrophy. Authorities hitherto are sults obtained different sized test ob- fairly well agreed.* We may quote Wilbrand by using and jects and different intensities of Saenger as having produced the most monu- illumination, as do a considerable mental work on the subject. After out showing they very increase pointing in the area with the frequent absence of visual disturbances for seeing larger and better lighted a surprisingly long time after marked objects, points unmistakably to the fact that changes what we are is a not an ab- are visible with the and men- measuring relative, ophthalmoscope solute quantity.
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